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Unlisted Face or Jaw Prosthesis Service

Montana rates for HCPCS 21089

Covers the making or fitting of an artificial replacement for a missing or damaged part of the face, jaw or mouth when no standard named service applies. These custom devices restore appearance and function after cancer surgery, injury, or a condition present from birth. Because each one is built for a single person, the specialist records exactly what was designed and fitted.

Rates data updated July 2026.

How much rates vary

Facilitymedian $631 · 10th to 90th $501 to $692Professionalmedian $85 · 10th to 90th $79 to $692
$100$200$500facility $631professional $85

Distribution of negotiated rates across all payers (price axis is log-scale). Each curve is scaled to its own total: facility and professional rates are different services, shown together to compare where they cluster. Small sample; interpret with caution. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$501.19
Median
$630.96
Typical High
$691.83
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$501.19
Median
$630.96
Typical High
$691.83
Providence
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$79.43
Typical High
$85.11